EMS request for information

This form is for Emergency Medical Services (EMS) personal to submit information about pediatric patients they deliver to Children's Hospital of Wisconsin's Emergency Department/Trauma Center. Our policy allows for two requests per patient by EMS.

Fill in the following information:

Requestor's Information

Full name

Email address

Phone number

Name of service

Training officer/EMS division chief

Patient's Information

Full name

Provider address

Date of birth (MM/DD/YYYY)

Date of service (MM/DD/YYYY)

Type of request

Urgent (Follow up within 48 hours)

Non-urgent (Follow up within pre-arranged timeframe)

Reason for transfer

Trauma

Medical

Specific questions or comments:

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Note: Please make sure run sheet is available. Fax run sheet to Children's Hospital of Wisconsin's Emergency Room/Trauma Center (ER/TC) at (414) 266-2496.